How do the mindfulness and sensory-behavioural-emotional aspects influence the painful experience related to temporomandibular disorder?

BACKGROUND: Chronic pain is persistent or recurrent pain lasting longer than 3 months. The experience of temporomandibular disorder (TMD)-related pain is modulated by emotional and social factors, with mindfulness encapsulating these aspects. OBJECTIVE: To investigate the association between cognitive-behavioural-emotional characteristics, mindfulness and the painful experience in women with chronic pain-related TMD. METHODS: A cross-sectional study was conducted, including 90 women aged between 18 and 61 years old, diagnosed with chronic pain-related TMD according to the Diagnostic Criteria for Temporomandibular Disorder, considering both temporomandibular joint and muscle pain. Specific instruments were employed to assess cognitive-behavioural-emotional aspects. The Mindful Attention Awareness Scale and the Five Facets of Mindfulness Questionnaire scales evaluated the level and construct of mindfulness. The relationship between variables was analysed using bivariate association tests (.05 > p < .20), followed by multiple regression tests (p < .05). RESULTS: The heightened experience of pain correlated with increasing age, a low level of education, the attribution of the locus of control by chance, and lower levels of mindfulness (p < .05). The heightened experience of pain was negatively influenced by mindfulness levels (p < .05). On the other hand, the painful experience was mainly influenced by facets describing negative formulation, distraction, non-reactivity and non-judgement (p < .05). CONCLUSION: Demographic, cognitive-behavioural-emotional data and levels of mindfulness and its facets presented different influence weights on the painful experience. These findings provide support for future studies focusing on mindfulness strategies, education and pain management in women with chronic pain-related TMD.

A Randomized Controlled Trial Evaluating the Levels of the Biomarkers hs-CRP, IL-6, and IL-8 in Patients with Temporomandibular Disorder Treated with LLLT, Traditional Conservative Treatment, and a Combination of Both.

Temporomandibular disorders (TMDs) are a type of idiopathic orofacial pain. Inflammation, particularly elevated circulating levels of high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), and interleukin-8 (IL-8), has been linked to pain symptoms. The purpose of this study was to compare hs-CRP, IL-6, and IL-8 biomarkers and pain intensity with different treatment strategies (LLLT, standard conservative treatment, and combination) for TMD patients. METHODS: A total of 32 participants were randomly included in the study and divided into three groups (Group I, Group II, and Group III) referred from the Dental Clinic, School of Dental Science, HUSM. Patients received LLLT (Groups II and III) in five sessions for the duration of 10 days. Patients in Groups I and III received standard conservative TMD treatment (diet and stress counseling, jaw exercises, physical therapy, which was a hot towel application) by the principal investigator. All blood samples for biomarkers were performed before starting treatments and directly after finishing the treatment protocols, where all results were recorded. RESULTS: The result showed a significant difference in the mean IL-8 (p = 0.001) between the three intervention groups (LLLT, standard treatment, and combined treatment). IL-6 showed an increase in the mean of IL-6 levels from baseline to post-treatment with a better mean in the LLLT treatment group without any significant differences. Additionally, there were no significant mean differences found between the groups and in the group for the hs-CRP biomarker. CONCLUSIONS: A statistically non-significant difference was found in hs-CRP and IL-6 before and after LLLT, conservative, and combined treatment strategies of TMD. A statistically significant difference was observed in the mean levels of IL-8 between the LLLT intervention group and the combined treatment group. Although there was no statistically significant correlation between pain intensity and biomarkers, a statistically significant difference was found in pain intensity before and after LLLT, conservative, and combined treatment strategies. TMJ degeneration could be exacerbated by elevated IL-8 levels. Thus, this can be an important biomarker to mark or identify the painful condition of TMJ.

Auricular acupuncture in TMD - A sham-controlled, randomized, clinical trial.

This study evaluated the effect of auricular acupuncture (AA) on physical (PA) and emotional (EA) aspects of patients with temporomandibular disorders (TMDs) and compared the effect of AA with those of Sham and occlusal splints (OS). In accordance with the CONSORT guidelines, patients with TMDs were evaluated by axes I and II of the RDC-TMD. The patients were allocated among three groups: OS, Sham and AA; and followed for 8 weeks. Both intragroup and intergroup evaluation for quantitative variables were analyzed with ANOVA, one-way, followed by the Tukey test. Qualitative variables were analyzed with the Kruskal-Wallis, and Dunn tests (intergroup evaluation) and for intragroup analyses, the Friedman and Wilcoxon tests were applied. At the end of the experiment, the chi-squared test was applied to compare the three groups with respect to the number of variables that had shown improved scores. The adopted level of significance for all tests was α = 5%. Intragroup analysis showed that, in the Sham group, no improvement in performance was seen in either EA and significant was improvements in 5 variables for 9 for PA, while in the AA group, significant improvements were observed in 2 variables for EA and in 9 for PA. In the OS group at the end of this study, significant improvements were observed in 8 and 8 variables for EA and PA, respectively. The analysis of therapies used revealed that the number of variables exhibiting significantly improved outcomes after treatment was similar between the AA and OS groups, whereas the sham group showed statistically significant differences when compared with the other two groups. In conclusion, this study demonstrated that AA applied at a specific TMJ ear point was able to bring about improvements in patients with TMDs, with outcomes similar to those in patients treated with an OS. CLINICAL TRIAL REGISTRATION: RBR-69ynnw (Brazilian Registry of Clinical Trials).

Influence of Clinical, Physical, Psychological, and Psychophysical Variables on Treatment Outcomes in Somatic Tinnitus Associated With Temporomandibular Pain: Evidence From a Randomized Clinical Trial.

OBJECTIVE: To assess the influence of clinical, psychological, and psychophysical variables on treatment outcomes after application of exercise combined with education with/without manual therapy in people with tinnitus associated with temporomandibular disorder (TMD). METHODS: A secondary analysis of a clinical trial was performed investigating the effectiveness of including cervico-mandibular manual therapy into an exercise combined with education program in 61 subjects with TMD-related tinnitus. Clinical outcomes including tinnitus severity and tinnitus-related handicap were assessed at 3 and 6 months post-intervention. Patients were assessed at baseline for clinical (tinnitus severity, tinnitus-related handicap, quality of life), physical (range of motion), psychological (depression), and psychophysical (pressure pain thresholds [PPTs]) variables that were included as predictors. RESULTS: The regression models indicated that higher scores of tinnitus severity at baseline predicted better outcomes 3 and 6 months post-intervention (explaining 13% to 41% of the variance) in both groups. Higher scores of tinnitus-related handicap at baseline predicted better outcome of tinnitus-related handicap (45% variance) in the manual therapy with exercise/education group. Lower PPTs over the temporalis muscle at baseline predicted poorer clinical outcomes (10.5% to 41% of the variance) in both groups. Other predictors were sex and quality of life (6.7% variance) in the manual therapy group and PPTs over the masseter muscle (5.8% variance) in the exercise/education group. CONCLUSION: This study found that baseline tinnitus severity and localized PPT over the temporalis muscle were predictive of clinical outcomes in individuals with TMD-related tinnitus following physical therapy. Other predictors (eg, sex, quality of life) were less influential.

Music Modulates Awake Bruxism in Chronic Painful Temporomandibular Disorders.

OBJECTIVE: In this experimental study, we aimed to determine whether guided music listening (GML) - a music intervention based on models of mood mediation and attention modulation - modulates masticatory muscle activity and awake bruxism in subjects with chronic painful muscular temporomandibular disorders (TMD myalgia, mTMD), a condition causing a significant burden to patients, their families, and healthcare systems. BACKGROUND: Awake bruxism - a stress behavior characterized by clenching of the teeth - is a strong contributor to chronic mTMD. GML modulates psychological stress and motor responses and could thus reduce muscle activity in chronic musculoskeletal conditions, including mTMD. METHODS: We recorded the electromyographic (EMG) activity in the right masseter of 14 women with chronic (>6 months) mTMD (median [IQR] = 39.5.3 [24.3] years) and 15 pain-free women (median [IQR] = 30.0 [3.5] years) during a GML session, including 3 music (stressful, relaxing, and participants' favorite music) and a no-music (pink noise) control blocks, each lasting 15 minutes. We measured the motor effort of the right masseter relative to the participants' maximum voluntary contraction (MVC), the muscular effort to maintain mandibular posture (EMGposture ), and to produce spontaneous awake bruxism episodes (EMGbruxism ), and the duration and frequency of spontaneous awake bruxism episodes. We tested between-group and within-group (between blocks) differences, as well as the effect of the interaction group by experimental block on these outcome measures. RESULTS: In both groups, EMGposture was significantly affected by the interaction group by experimental block (P < .001). Compared to pink noise [mean (95% CI); mTMD: 2.2 (1.6-2.8) %MVC; Controls: 1.1 (0.5-1.7) %MVC], EMGposture increased during the stressful music block [contrast estimate (95% CI); mTMD: +0.8 (0.7-0.8) %MVC; Controls: +0.3 (0.3-0.4) %MVC; both P < .001], and decreased during the relaxing [mTMD: -0.4 (-0.5 to -0.4) %MVC; Controls: -0.3 (-0.4 to -0.3) %MVC; both P < .001] and favorite [mTMD: -0.5 (-0.6 to -0.5) %MVC; Controls: -0.5 (-0.5 to -0.4) %MVC; both P < .001] music blocks. EMGposture was greater in mTMD individuals than controls during the favorite music [contrast estimate (95% CI): +1.1 (0.2-1.9) %MVC; P = .019] and the pink noise [+1.1 (0.2-2.0) %MVC; P = .014] blocks. EMGbruxism was significantly affected by the interaction group by experimental block (P < .001). In mTMD participants, compared to the pink noise block [mean (95% CI); 23.8 (16.0-31.6) %MVC], EMGbruxism increased during the stressful music block [contrast estimate (95% CI); +10.2 (8.6-11.8) %MVC], and decreased during the relaxing [-6.2 (-8.1 to -4.3) %MVC; P < .001] and favorite [-10.2 (-12.2 to -9.1) %MVC; P < .001] music blocks. These effects were not observed in the control group [mean (95% CI); pink noise: 19.3 (10.9-27.6); stressful: 21.2 (12.9-29.4) %MVC; relaxing: 21.6 (13.3-29.9) %MVC; favorite: 24.2 (15.8-32.7) %MVC; all P > .05]. EMGbruxism was significantly greater in mTMD participants than controls during the stressful music block [contrast estimate (95% CI): +12.9 (1.6-24.2) %MVC; P = .026). GML did not affect the duration or the frequency of awake bruxism in either group (median [IQR], mTMD: 23.5 [96.7] s, range 1-1300 seconds; Controls: 5.5 [22.5], range 0-246 seconds; P = .108). The frequency of awake bruxism episodes was greater in the mTMD group compared to controls only during the pink noise block (median [IQR], mTMD: 5 [15.3] episodes, range 0-62 episodes; Controls: 1 [3] episode, range 0-27 episodes; P = .046). No significant between-group differences were found in either the overall time spent engaging in awake bruxism (median [IQR], mTMD: 23.5 [96.7] s, range 1-1300 seconds; Controls: 5.5 [22.5], range 0-246 seconds; P = .108), or during each block (all P > .05). CONCLUSIONS: In subjects with chronic mTMD, relaxing music and the individual's favorite music decreased the muscular effort during spontaneous awake bruxism episodes by 26% and 44% (relative changes), respectively. In contrast, stressful music increases it by about 43%. Because of its positive effects on awake bruxism, GML with selected music could be a promising and non-invasive component of a multimodal approach for the management of chronic mTMD.

Prior Therapeutic Experiences, Not Expectation Ratings, Predict Placebo Effects: An Experimental Study in Chronic Pain and Healthy Participants.

INTRODUCTION: Many clinical trials fail because of placebo responses. Prior therapeutic experiences and patients' expectations may affect the capacity to respond to placebos in chronic disorders. OBJECTIVE: The scope of this study in 763 chronic orofacial pain and healthy study participants was to compare the magnitude and prevalence of placebo effects and determine the putative role of prior therapeutic experiences vs. expectations. METHODS: We tested placebo propensity in a laboratory setting by using 2 distinct levels of individually tailored painful stimulations (high pain and low pain) to reinforce expectations and provide a hypoalgesic experience (conditioning phase). Afterwards, both levels of pain were surreptitiously set at a moderate pain level to test for placebo effects (testing phase). Pain and expectation ratings were assessed as primary outcomes using visual analog scales. RESULTS: In both chronic pain and healthy participants, placebo effects were similar in magnitude, with the larger prevalence of responders in the healthy participants. Although chronic pain participants reported higher pain relief expectations, expectations did not account for the occurrence of placebo effects. Rather, prior experience via conditioning strength mediated placebo effects in both pain and healthy participants. CONCLUSIONS: These findings indicate that participants with chronic pain conditions display robust placebo effects that are not mediated by expectations but are instead directly linked to prior therapeutic experiences. This confirms the importance of assessing the therapeutic history while raising questions about the utility of expectation ratings. Future research is needed to enhance prediction of responses to placebos, which will ultimately improve clinical trial designs.

Effects of low-power laser auriculotherapy on the physical and emotional aspects in patients with temporomandibular disorders: A blind, randomized, controlled clinical trial.

OBJECTIVES: This study evaluated the effects of low-power laser auriculotherapy (LA) on the physical and emotional symptoms of patients with temporomandibular disorders (TMDs), in comparison with occlusal splints (OS). DESIGN: Randomized, blinded, prospective, non-inferiority clinical trial. INTERVENTIONS: The patients received OS (control group) or LA (experimental group). MAIN OUTCOME MEASURES: Following the Consolidated Standards of Reporting Trials (CONSORT) guidelines, patients with TMD were evaluated by using axes I and II of the Research Diagnostic Criteria for RDC-TMD. Both intra- and intergroup quantitative variables were analyzed with ANOVA (p < 0.05), while qualitative variables were analyzed with the Kruskal-Wallis (intergroup evaluations; p < 0.05) or Mann-Whitney tests (intragroup analyses; p < 0.05). RESULTS: OS improved five physical symptoms of TMD (pain in the right temporal muscle, right and left masseter muscles, left joint, and left intraoral region), while LA improved six (jaw functioning; pain in left masseter muscle, right and left joints, and right and left intraoral regions). Similarly, OS improved seven emotional symptoms (degree of depression, degree of non-specific physical symptoms, excluding pain, degree of non-specific physical symptoms including pain, average pain value in the past 6 months, presence of depression, intensity and characteristics of pain, non-specific physical symptoms including pain), while LA improved five (degree of non-specific physical symptoms including pain, presence of depression, intensity and characteristics of pain, non-specific physical symptoms including pain, non-specific physical symptoms excluding pain). CONCLUSION: LA improved the physical and emotional symptoms of TMD, with results similar to OS. CLINICAL RELEVANCE: For the physical and emotional symptoms associated with TMD, LA showed similar outcomes as OS.

Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial.

The effectiveness of photobiomodulation (PBM) and manual therapy (MT), alone or combined (CT), were evaluated in pain intensity, mandibular movements, psychosocial aspects, and anxiety symptoms of temporomandibular disorder (TMD) patients. Fifty-one TMD patients were randomly assigned to three groups: the PBM group (n = 18), which received PBM with 808 nm, 100 mW, 13.3 J/cm2, and 4 J per point; the MT group (n=16) for 21 minutes each session on masticatory muscles and temporomandibular joint TMJ; and the CT group (n = 17), applied during twelve sessions. Seven evaluations were performed in different moments using visual analogue scale (VAS), Research Diagnosis Criteria for Temporomandibular Disorders (RDC/TMD) Axis I and II, and Beck anxiety inventory (BAI). All groups demonstrated reductions in pain and improvement in jaw movements during treatment and at follow-up (< 0.001). The assessment of psychosocial aspects of TMD, comparing baseline and follow-up in all treatment groups, revealed that treatment did not promote modification in the intensity of chronic pain (p > 0.05). However, depression symptoms showed a reduction in PBM and CT groups (p≤0.05). All treatments promoted reduction in physical symptoms with and without pain and enhancement of jaw disabilities (p ≤ 0.05). MT promotes improvement in 5 functions, PBM in 2, and CT in 1 (p < 0.001). BAI analysis revealed that all treatments lead to a reduction in anxiety symptoms (p≤0.05). All protocols tested were able to promote pain relief, improve mandibular function, and reduce the negative psychosocial aspects and levels of anxiety in TMD patients. However, the combination of PBM and MT did not promote an increase in the effectiveness of both therapies alone.

Effectiveness of osteopathic manipulative treatment versus osteopathy in the cranial field in temporomandibular disorders - a pilot study.

PURPOSE: Temporomandibular disorders are a common musculoskeletal condition causing severe pain, physical and psychological disability. The effect and evidence of osteopathic manipulative treatment and osteopathy in the cranial field is scarce and their use are controversial. The purpose of this pilot study was to evaluate the effectiveness of osteopathic manipulative treatment and osteopathy in the cranial field in temporomandibular disorders. METHODS: A randomized clinical trial in patients with temporomandibular disorders was performed. Forty female subjects with long-term temporomandibular disorders (>3 months) were included. At enrollment, subjects were randomly assigned into two groups: (1) osteopathic manipulative treatment group (20 female patients) and (2) osteopathy in the cranial field group (20 female patients). Examination was performed at baseline (E0) and at the end of the last treatment (E1), consisting of subjective pain intensity with the Visual Analog Scale, Helkimo Index and SF-36 Health Survey. Subjects had five treatments, once a week. 36 subjects completed the study (33.7 ± 10.3 y). RESULTS: Patients in both groups showed significant reduction in Visual Analog Scale score (osteopathic manipulative treatment group: p = 0.001; osteopathy in the cranial field group: p< 0.001), Helkimo Index (osteopathic manipulative treatment group: p = 0.02; osteopathy in the cranial field group: p = 0.003) and a significant improvement in the SF-36 Health Survey - subscale "Bodily Pain" (osteopathic manipulative treatment group: p = 0.04; osteopathy in the cranial field group: p = 0.007) after five treatments (E1). All subjects (n = 36) also showed significant improvements in the above named parameters after five treatments (E1): Visual Analog Scale score (p< 0.001), Helkimo Index (p< 0.001), SF-36 Health Survey - subscale "Bodily Pain" (p = 0.001). The differences between the two groups were not statistically significant for any of the three target parameters. CONCLUSION: Both therapeutic modalities had similar clinical results. The findings of this pilot trial support the use of osteopathic manipulative treatment and osteopathy in the cranial field as an effective treatment modality in patients with temporomandibular disorders. The positive results in both treatment groups should encourage further research on osteopathic manipulative treatment and osteopathy in the cranial field and support the importance of an interdisciplinary collaboration in patients with temporomandibular disorders. Implications for rehabilitation Temporomandibular disorders are the second most prevalent musculoskeletal condition with a negative impact on physical and psychological factors. There are a variety of options to treat temporomandibular disorders. This pilot study demonstrates the reduction of pain, the improvement of temporomandibular joint dysfunction and the positive impact on quality of life after osteopathic manipulative treatment and osteopathy in the cranial field. Our findings support the use of osteopathic manipulative treatment and osteopathy in the cranial field and should encourage further research on osteopathic manipulative treatment and osteopathy in the cranial field in patients with temporomandibular disorders. Rehabilitation experts should consider osteopathic manipulative treatment and osteopathy in the cranial field as a beneficial treatment option for temporomandibular disorders.

Comparative effectiveness of photobiomodulation and manual therapy alone or combined in TMD patients: a randomized clinical trial

Abstract The effectiveness of photobiomodulation (PBM) and manual therapy (MT), alone or combined (CT), were evaluated in pain intensity, mandibular movements, psychosocial aspects, and anxiety symptoms of temporomandibular disorder (TMD) patients. Fifty-one TMD patients were randomly assigned to three groups: the PBM group (n = 18), which received PBM with 808 nm, 100 mW, 13.3 J/cm2, and 4 J per point; the MT group (n=16) for 21 minutes each session on masticatory muscles and temporomandibular joint TMJ; and the CT group (n = 17), applied during twelve sessions. Seven evaluations were performed in different moments using visual analogue scale (VAS), Research Diagnosis Criteria for Temporomandibular Disorders (RDC/TMD) Axis I and II, and Beck anxiety inventory (BAI). All groups demonstrated reductions in pain and improvement in jaw movements during treatment and at follow-up (< 0.001). The assessment of psychosocial aspects of TMD, comparing baseline and follow-up in all treatment groups, revealed that treatment did not promote modification in the intensity of chronic pain (p > 0.05). However, depression symptoms showed a reduction in PBM and CT groups (p≤0.05). All treatments promoted reduction in physical symptoms with and without pain and enhancement of jaw disabilities (p ≤ 0.05). MT promotes improvement in 5 functions, PBM in 2, and CT in 1 (p < 0.001). BAI analysis revealed that all treatments lead to a reduction in anxiety symptoms (p≤0.05). All protocols tested were able to promote pain relief, improve mandibular function, and reduce the negative psychosocial aspects and levels of anxiety in TMD patients. However, the combination of PBM and MT did not promote an increase in the effectiveness of both therapies alone.

Integration of mental health screening in the management of patients with temporomandibular disorders.

Mental health disorders such as depression or anxiety, or both, are more common in patients with temporomandibular disorders (TMD) (16%-40%) than in the general population (16%), and failure to recognise them may be detrimental to the management of TMD. Paper-based screening tools previously reported in this group require assessment by clinicians and subsequent collation of data. We describe our experience of a new system - IMPARTS (Integrating mental and physical: research training and services), which uses validated tools to identify and to monitor the progress of patients who may benefit from psychological intervention. At outpatient clinics, patients used an electronic tablet to complete the General Anxiety Disorder Questionnaire (GAD-7), the Patient Health Questionnaire (PHQ-9), the Inclusion of Oral Health Impact Profile (OHIP-14), and the Brief Pain Inventory (BPI). Data were linked directly to their electronic record to allow the results, with suggestions for treatment, to be reviewed immediately during the consultation. A total of 162 patients were included. Screening showed that referral was required in 28 (17%) with a probable major depressive disorder and 32 (20%) with a general anxiety disorder. Two (1%), who were identified as being at high risk of suicide or self-harm, were referred for immediate psychological assessment. Use of the system can aid the holistic treatment of patients with TMD through appropriate referral. Early identification of mental health problems and concurrent management are most beneficial in those who have had symptoms of TMD for up to two years, and are therefore essential.

Orthognathic treatment of dentofacial disharmonies: its impact on temporomandibular disorders, quality of life, and psychosocial wellness.

AIM: The objective of this literature review was to assess the effect of orthognathic surgical treatment on temporomandibular disorders (TMD), quality of life (QoL), and psychosocial wellness. METHODS: Journal articles and systematic reviews published in English between 1982 and 2015 were searched using PubMed, MEDLINE, and Cochrane database using the search terms "orthognathic," "temporomandibular disorders," "quality of life," and "psychosocial." The articles were then reviewed and discussed. RESULTS: Both objective and subjective parameters play a role in orthognathic treatment outcome satisfaction and QoL. Psychological factors and TMD exerted a stronger influence on patients' QoL more than objective treatment outcome measures. CONCLUSION: A paradigm shift in clinical mindset from solely objective measures to a more holistic, patient-centric approach of addressing patients' expectations and improving QoL is warranted when treating patients with dentofacial disharmonies.

Treatment Seeking and Self-Constructed Explanations of Pain and Pain Management Strategies Among Adolescents with Temporomandibular Disorder Pain.

AIMS: To explore adolescents' explanations of their temporomandibular disorder (TMD) pain, their pain management strategies for TMD pain, and their treatment-seeking behavior. METHODS: One-on-one interviews were conducted with 21 adolescents aged 15 to 19 years who had TMD pain and followed a semistructured interview guide. Subjects were strategically selected from patients referred to an orofacial pain clinic. All participants had been examined and received a pain diagnosis based on the Research Diagnostic Criteria for TMD. The interviews focused on the adolescents' experiences of TMD pain, their strategies for handling pain, and how they seek care. The interviews were recorded, transcribed verbatim, and analyzed using qualitative manifest content analysis. RESULTS: Qualitative manifest content analysis revealed two categories: (1) self-constructed explanations, with three subcategories (situation-based explanatory model, physical/biologic model, and psychological explanatory model); and (2) pain management strategies, with four subcategories (social support, treatment, relaxation/rest, and psychological strategies). Adolescents used physical activities and psychological and pharmacologic treatment to manage pain. Reasons for seeking treatment were to be cured, to obtain an explanation for their pain, and because their symptoms bother others. CONCLUSION: Adolescents living with TMD pain develop self-constructed explanations and pain management strategies. With access to these descriptions, dentists can be better prepared to have a dialogue with their adolescent patients about their own explanations of pain, the nature of pain, and in which situations the pain appears. Dentists can also explore adolescent patients' pain management strategies and perhaps also suggest new treatment strategies at an earlier stage.

Pain-Related Temporomandibular Disorder - Current Perspectives and Evidence-Based Management.

Pain-related temporomandibular disorder (TMD) is one of the top three most common chronic pain conditions, along with headaches and back pain. TMD has complex pathophysiology and significant associations with a variety of other chronic pain conditions, eg fibromyalgia, irritable bowel syndrome and migraine. Chronic TMD is associated with a negative impact upon quality of life and high levels of healthcare utility. It is important that clinicians are able to diagnose TMD correctly, provide appropriate management in keeping with current evidence-based practice, and identify when to refer patients to specialist care. The presence of risk factors, eg anxiety, depression, pain-related disability and chronic pain conditions elsewhere in the body, may help to identify which TMD patients require referral for multidisciplinary management. TMD should be managed using a holistic approach, incorporating patient education and encouragement towards self-management. TMD care pathways should consider using the three'pillars'of pain management: physical therapies, pharmacotherapy and clinical psychology.

Effects of exercise training and photobiomodulation therapy (EXTRAPHOTO) on pain in women with fibromyalgia and temporomandibular disorder: study protocol for a randomized controlled trial.

BACKGROUND: Fibromyalgia (FM) is a syndrome most prevalent in women, in whom it is characterized mainly by chronic pain. An important issue is that many patients with FM are reported to have temporomandibular dysfunction (TMD), and the coexistence of these pathologies generates a clinical outcome of high complexity. The literature is unclear regarding an effective therapy for reducing pain in patients with both comorbidities. Exercise training and phototherapy (low-level laser therapy with light-emitting diode) are two of the approaches used to treat pain. Thus, the aim of this study is to assess the potential role of exercise training plus phototherapy in reducing chronic pain in women with FM and TMD. A further aim is to determine whether the interventions can improve quality of life and modulate endogenous serotonin. METHODS/DESIGN: A randomized controlled clinical trial will be conducted. It will involve 60 women ≥ 35 years of age with a diagnosis of FM and TMD. After recruitment, patients will be randomly allocated to one of four groups: a control group (no intervention), a group that will receive a phototherapy intervention (PHO), a group that will be prescribed muscle-stretching, aerobic, and facial exercises (EXT), or a group that will receive phototherapy plus exercise interventions (PHO + EXT). The trial will last 10 weeks, and the following outcomes will be evaluated on two separate occasions (baseline and within 24 h after the last day of the protocol). Pain intensity will be analyzed using a visual analogue scale and the McGill Pain Questionnaire, and pain thresholds will be punctuated using a digital algometer. FM symptoms will be assessed using the Fibromyalgia Impact Questionnaire, and quality of life will be determined with the 36-item Short Form Health Survey. Serotonin levels will be evaluated in salivary samples using a competitive enzyme-linked immunosorbent assay. DISCUSSION: This is the first randomized controlled trial in which the role of phototherapy, exercise training, and a combination of these interventions will be evaluated for chronic pain in patients with FM and TMD. The results will offer valuable clinical evidence for objective assessment of the potential benefits and risks of procedures. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02279225. Registered 27 October 2014.

Accuracy of the Fonseca anamnestic index in the identification of myogenous temporomandibular disorder in female community cases.

The aim of the present study was to evaluate the accuracy of the Fonseca anamnestic index (FAI) in the identification of myogenous temporomandibular disorder (TMD). Two hundred and three female volunteers participated in this study, 117 with myogenous TMD and 86 without TMD. The Research Diagnostic Criteria for Temporomandibular Disorders were first applied as the gold standard for the diagnosis. The volunteers then answered the 10 items on the FAI, which furnished a score ranging from 0 to 100 points. The receiver operating characteristic (ROC) was used to determine the accuracy of the diagnosis (area under the curve) and the best cutoff point of the tool. Thus, FAI demonstrated a high degree of accuracy for the diagnosis of myogenous TMD (area under the ROC curve of 0.940). The best cutoff point was a score of 47.50. Thus, a score ranging from 0 to 45 points corresponds to the absence of myogenous TMD and scores ranging from 50 to 100 points identifies individuals with the disorder. In conclusion, the high degree of diagnostic accuracy demonstrates that the FAI can be employed for the identification of myogenous TMD in female community cases.

Evaluation of pain, jaw movements, and psychosocial factors in elderly individuals with temporomandibular disorder under laser phototherapy.

Few studies have been carried out on the application of laser phototherapy (LPT) for treating painful temporomandibular disorder (TMD) in elderly population that is growing worldwide. The aim of the present study was to evaluate the pain, jaw movements, and psychosocial factors in ten elderly patients with painful TMD before and after LPT. All patients were evaluated before and after LPT by using the Research Diagnostic Criteria for temporomandibular disorders (RDC/TMD) axes I and II. For pain assessment, a visual analogue scale (VAS) was used. The LPT was carried out with an GaAlAs diode laser (780 nm; spot size 0.04 cm(2)) in punctual and contact mode. Two settings of irradiations were applied as follows: in patients presenting myofascial pain, 10 mW, 5 J/cm(2), 20 s, 0.2 J per application point; and in patients with joint TMD, 70 mW, 105 J/cm(2), 60 s on five points, 4.2 J per point. Two sessions of LPT were carried out per week over four consecutive weeks, in the total of eight sessions. Data was statistically analyzed (p < 0.05). Significant pain reduction was found in all patients. There were increase in maximum mouth opening without pain and reduction in muscle pain during right and left lateral excursion. A significant reduction in chronic pain severity (p = 0.02) and significant improvements in depression (p = 0.038) and nonspecific physical symptoms with pain (p = 0.0167) were observed. The present findings indicate that LPT is able to promote pain relief and improvement of jaw movements in elderly patients with TMD, with a positive effect on psychosocial aspects.

Evaluation of arthrocentesis with hyaluronic acid injection plus oral glucosamine hydrochloride for temporomandibular joint osteoarthritis in oral-health-related quality of life.

OBJECTIVES: To evaluate the changes in oral-health-related quality of life (OHRQoL) in patients with temporomandibular joint osteoarthritis (TMJ-OA) who underwent five weekly hyaluronic acid injections together with oral glucosamine hydrochloride for three months. MATERIALS AND METHODS: This prospective observational study included 211 consecutive patients who completed the Chinese version of the 14-item Oral Health Impact Profile (OHIP-C14) before treatment (T0), and at first month (T1), third month (T2), and sixth month (T3) after the first injection. RESULTS: Significant changes in the summary scores on OHIP-C14 were observed during follow-up (P < 0.001). The scores were significantly reduced at T1, T2, and T3 compared with T0 (P < 0.001), and were significantly reduced from T0 to T1 (P < 0.001) and T1 to T2 (P < 0.001), but not from T2 to T3 (P = 0.369). Compared with the norms, the scores were significantly higher at T0 (P < 0.001), not significantly different at T1 (P = 0.482), and significantly lower at T2 (P = 0.013) and T3 (P = 0.003). The changes in the scores differed significantly among age groups (P = 0.012) but not between sexes (P = 0.293). CONCLUSIONS: TMJ-OA has a negative effect on patient OHRQoL. OHRQoL scores were improved to normal levels in both the short and long terms after therapy. OHRQoL improvement was the greatest in the youngest group, but did not differ between the sexes.